Medical Insurance Companies Have Run Amock...Time for a Single Payer Smack down

Insurance companies are out of control. The health system is so out of wack and the insurance companies have no fear of reprisal.  They are in need of a single payer smack down. 

When I got into my office this morning I was informed by my office manager that an insurance company had called and was requesting a refund for overpayment for patients that were seen in the office in 2005-2006.
I was pretty angry until I started to think about it.  It dawned on me that I had received a letter from a different insurance company asking for reimbursement for surgery that was done in Sept 2008. It turns out they had only partially paid me for the surgery that I had done. Now they were asking for a reimbursement?  That would mean that I would be paying THEM for the privilege of operating on their patient.
After the anger cooled a bit, I got suspicious. The last time that I had gotten a letter for an 'over payment' was over 4 years ago. So I contacted a colleague. They had also been receiving letters requesting reimbursement of 'over paid' claims dating back to 2003. Apparently, the insurance companies have devised another way to squeeze more money out of providers. They seem to alternate between extracting money from the employers with higher premiums, to gouging patients in the form of higher premiums along with higher deductibles and coinsurance, to cheating physicians in the form of increased claim denials, decreasing reimbursements, and requesting re-payments for what they deem "over payments".
Without getting too technical...after a patient is seen, the doctor will generate a claim form. On that form there are codes that are submitted. Certain points must be present within the history, physical examination and treatment plan to be able to submit a specific code for which the insurance company will then pay the allowed amount.
There are certain rules that a doctor/medical professional must follow as per the contract with the insurance company:
1.      The claims must be submitted in a standardized manner i.e., coded using specific designations.
2.      The claims must be submitted within a certain time frame (less than 120 days) if the claim is not submitted within that time it cannot be submitted and it will not be paid.
3.      Once a physician obtains pre-authorization for a service or procedure, the insurance company will pay the allowed amount for the procedure.
Sounds pretty straight forward right?  If it was a level playing field it would be pretty easy to navigate. In return for following the above mentioned rules, one would think that the patient and the physician have the right to expect that the insurance company will be a liaison between them to insure that appropriate medical care is given and payment of benefits are coordinated smoothly. In short, that the best interests of the patient as determined by the physician and the patient are achieved.
....but it is not a level playing field. Did we really think that it would be?
The whole point of a company (and an insurance company is no different) is to make money. In the case of an insurance company they make money by charging premiums and paying out as little in claims as possible. In the case of car insurance - if you get into a wreck you are more likely to want to take care of it yourself and not involve the insurance company to keep your premiums from going up. We all saw what flood insurance was like in the case of those affected by Katrina. The insurance companies found a way not to cover water damage because it was due to a natural disaster like a hurricane and not a ruptured pipe in the house. Do we really expect health insurance companies to care whether we have cancer and need a bone marrow transplant or gene therapy? The thought that a health insurance company would have your best interests when it affects their bottom line is fundamentally flawed.
The insurance companies have devised and continue to devise tricks to avoid paying a claim in a timely way and to avoid paying the allowed amount. They have also increased the cost of medical care by building in a bureaucracy that forces the medical practice to waste time and to add more staff to work claims. The worst part is they have driven a wedge between the doctor and the patient. In my opinion their actions have been instrumental in taking the heart out of medicine.
In a previous diary, I spoke about the pressure physicians have to see more patients in less time to keep their doors open. It has led to the creation of physician extenders like physician assistants and has increased the role of nurse practitioners. More recently it has led to Wal-Mart medical care. It has now come to a point that in some practices patients have never met the physician after several office visits. The time spent by the physician taking the patient's history and getting to know the patient is the way to make a proper diagnosis and to avoid the pitfalls of over ordering tests in an attempt to practice defensive medicine. In my opinion the art of medicine is in danger of being irretrievably lost.
What can we do to get it back? I would argue that a system that allows for real competition needs to be created. The insurance companies have concentrated their power by consolidating and lobbying in Washington. At this point there are a handful of insurance companies that control the lion share of the market. With that power they have set unreasonably low prices that physicians/health care providers and hospitals have accepted if they wanted to see patients. They work with health insurance sales people to market policies that increase premiums for the employer that, since they rise every year, don't give an employer many options - either the employer has to change to an insurance policy with higher deductibles or coinsurance for the employee or drop coverage all together.
There is no pressure that can be brought to bear because there is nowhere to go.  If we apply universal health care coverage in this kind of environment, we will get the same affect as the Medicare drug coverage has brought. In short, the insurance companies will make a windfall in new premiums, but they will continue to ration care.  There will be further downward pressure on reimbursements and good doctors will leave the profession, and hospitals will close. At this point the health insurance companies are not held liable for denying necessary care in the event of a bad outcome. e.g., worsening of a disease or death because of denial of approval. What will happen when they become more powerful?
I have heard the argument that allowing people to shop around for a cheaper insurance from another state will allow the free market to work and fix everything. Right....didn't we already play this game with the financial industry?
The government is the only entity big enough to bring some pressure to bear. Unlike the commercial insurance industry, Medicare is not a for profit entity. Containing costs by eliminating the drive for profits will provide a market force that could drive premiums down and if done right can improve healthcare.
My thoughts....
1.      Allow people and employers to decide whether to pay their premiums into a government based system (Medicare for example since it already exists) VS paying insurance to commercial based carriers. If the government offers universal access regardless of pre-existing conditions, covers children, elaborates what is covered (e.g., no cosmetic procedures), begins to really cover preventative medicine - most people will opt for this. Either the commercial insurance companies would offer the same thing or they would have to get out of the business because they would have to compete to keep patients.
2.      Pay healthcare providers and hospitals a fare fee for their service in a timely way. Most doctors are not trying to be multi-millionaires. However, it is reasonable to be able to expect not to struggle to pay student loans, malpractice and the cost of doing business and have something left over.
3.   If more people paid into the pot of government based insurance, there would be more money available to deliver quality care.
4.      For those patients and employers that want to stay with their present commercial insurance they would be allowed to keep it. There could be some changes to lower cost. For example, if patients paid the doctor for office visits at the time those services were rendered and received payment directly from the insurance company that would lower pressure for physicians to raise fees since they would not have to wait up to 1 year for reimbursement.
The decision on health care is one of the most important debates that will take place this year. I believe that the future of medicine and the people of this country will be tied to the decision to make a real change or double down on the status quo. Last week I went to Washington DC to speak to my congressmen because I wanted them to understand what it is really like in the real word as a solo practitioner running a small business. If you have an idea about this, I suggest you do the same. If enough of people make their voices heard, I believe we can drown out the healthcare lobbyists and other special interest groups that are feeding off of our misery like vampires.
Crossposted at Daily Kos Health Care Series. On March 6, 2009, EFGSMO wrote another post on DKos, "An Honest Conversation About Healthcare Reform, Ins Companies and Dr/Patient Relationships."
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I assume that most of the folks interested in the single-payer options for health care are well aware of who is (or more like what is) the standing opposition.  There is certainly plenty of PR campaigning, beyond the obvious measures of who makes the most profit in doing the bussiness.

Though I was not fully tuned in, back when, I've recently done a pretty substantial look back at some of the history of the early to mid-90s attempt by the Clintons to create a national health care plan and have found just how much of the opposition was actually comprised of interests acting on behalf of Big Tobacco. 

Of course that industry is capable and on record for the grandest deceptions so it's no real surprise, and esepecially not in light of the fact that the industry was basically coordinated against "Hillarycare", as they called it, almost from the Clinton's Inauguration day because original plans would have been financed by a very substantial tax on tobacco products.

Their unified efforts pretty much evolved into what Hillary later described as the vast right wing conspiracy.

With that clear instruction to who and what eventually wrecked any chances of a health care plan for the nation -- imagine, successfully opposed by one of the biggest killers of American citizens!  -- I wonder how much anyone has tried to understand if there are larger hidden forces at play behind the scenes?

In case folks are interested to do that sort of thing, I thought it'd be useful to post links to the lobbying and lobbyist contributions databases where one can get much closer to the interests which are paying for access to those we elect. 

To tell the truth, I take the entire ability for non-voting corporations to essentially buy our elected officials as the very act of subverting democracy, somehow it remains legal. 

But at least you can get a sense of who's doing the subversion and who's actively in concert with those inteerests to do so.

Query the Lobbying Disclosure Act Database

Query the Lobbying Contributions Database

On the other hand, congratulations and thanks to you, efgsmo, for your active citizenship and the initiative you have made to lobby your representative.  I love stories like yours and very much appreciate your effort!

Best to you (and us) in its success.

"I hope we shall crush in its birth the aristocracy of our moneyed corporations which dare already to challenge our government in a trial of strength, and bid defiance to the laws of our country." - Thomas Jefferson

What has our government done, to convince people to hand over our very health freedoms for it to govern over?
Fannie Mae – bailout? (this is a government entity who's employee's receive bonuses!) What other government employee receives bonuses for doing their jobs?
Social security – bankrupt ? (robbed for other expenditures)
Medicaid – ? (robbed for other expenditures)
$2 trillion Porkulus bill - ? (and growing)
AIG – bail out, yet nobody knows where's the money gone? No committee of oversight in place (was promised by our representatives to be in place immediately)
Gas prices - ?(50% of every dollar at the pump goes to Washington) But who did you point your finger at as the problem????
Since our government "cannot" be sued, how will one be able to be recompensed for its malfeasance or neglect? How will the government, once it tells 300 million people "go see the doctor" we will pay all the bills, be able to control the consequences? By overwhelming our medical profession or break it, will come another grand government solution," we need more money to fix it"! You are already familiar and have accepted this excuse for too long, and know this to be their power solution. Our government has impoverished our families' financial freedom to pay our own way, by immoral taxation.

Furthermore how has Government run health care worked in other countries? Let's get past the emotions and examine the facts. A common example used to further the cause of "socialized medicine" in the United States is to point out how well it is working in countries such as France and Canada. However, those living in Canada know full well that their government run health care program is most certainly not working. As a matter of fact, many Canadian citizens choose to hire high priced brokers to find them quality health care right here in the United States because of the terrible bureaucracy that controls all forms of health care in Canada.

For more about what is really going on with the Canadian health care system please watch these short but very informative documentary videos:
The number of actual uninsured's in the US has also been grossly inflated as well. For the real numbers:

Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world. Economists, government officials, insurers and academics alike are beating the drum for a far larger government role in health care. Much of the public assumes their arguments are sound because the calls for change are so ubiquitous and the topic so complex. However, before turning to government as the solution, some unheralded facts about America's health care system should be considered, says Scott W. Atlas, a senior fellow at the Hoover Institution and a professor at the Stanford University Medical Center.

Americans have better survival rates than Europeans for common cancers:

* Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom.
* Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway.
* The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

Americans have better access to treatment for chronic diseases than patients in other developed countries:

* Some 56 percent of Americans who could benefit are taking statins, which reduce cholesterol and protect against heart disease.
* By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons and 17 percent of Italians receive them.

Lower income Americans are in better health than comparable Canadians:

* Twice as many American seniors with below-median incomes self-report "excellent" health compared to Canadian seniors (11.7 percent versus 5.8 percent).
* Conversely, white Canadian young adults with below-median incomes are 20 percent more likely than lower income Americans to describe their health as "fair or poor."

Americans spend less time waiting for care than patients in Canada and the United Kingdom:

* Canadian and British patients wait about twice as long -- sometimes more than a year -- to see a specialist, to have elective surgery like hip replacements or to get radiation treatment for cancer.
* All told, 827,429 people are waiting for some type of procedure in Canada.
* In England, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.

Source: Scott W. Atlas, "10 Surprising Facts About American Health Care," National Center for Policy Analysis, Brief Analysis No. 649, 3/24/09

Because of how the Single Payer System is designed Canadian citizens have NO WHERE NEAR the choices that we as American citizens do. As a matter of fact, until very recently (2005) it was simply not possible for a Canadian citizen to pay for their own health care or to purchase private medical insurance that would "bump them up the long waiting list" for medical treatments. The reason Canadian citizens now have the right to do so (and it is still limited) is a direct result of long hard battles (many that are still being fought) that have been waged by brave Canadian citizens like Dr. Jacques Chaoulli who took his clients case all the way to the Canadian supreme court and won! Dr. Chaoulli ( and his patient, George Zeliotis, launched their legal challenge to the Canadian government's monopolized healthcare system after waiting more than a year for hip-replacement surgery.

Canada's high court found for the plaintiffs and in doing so issued the following statement: "The evidence in this case shows that delays in the public healthcare system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public healthcare. The evidence also demonstrates that the prohibition against private health insurance and its consequence of denying people vital healthcare result in physical and psychological suffering that meets a threshold test of seriousness." Furthermore, Justice Marie Deschamps said, "Many patients on non-urgent waiting lists are in pain and cannot fully enjoy any real quality of life. The right to life and to personal inviolability is therefore affected by the waiting times."

Furthermore, the Vancouver, British Columbia-based Fraser Institute which keeps track of Canadian waiting times for various medical procedures. According to the Fraser Institute's 14th annual edition of "Waiting Your Turn: Hospital Waiting Lists in Canada (2006)," total waiting time between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, rose from 17.7 weeks in 2003 to 17.9 weeks in 2006. Depending on which Canadian province you live in, a simple MRI requires a wait between 7 and 33 weeks! Orthopedic surgery could require a wait of 14 weeks for a referral from a general practitioner to the specialist and then another 24 weeks from the specialist to treatment! For even more real life horror stories about Canadian citizens left in the lurch by the Canadian healthcare system read the well researched and fact based Wall Street Journal article entitled "Too Old For Hip Surgery" here: This is what happens when you put government in control of your health care decisions. Doing so in this country, would be nothing short of a train wreck. Anyone who thinks otherwise is simply uninformed or "willfully ignorant".

Real healthcare reform can be accomplished through consumer education, weeding out abuse of existing Federal entitlement programs (via a legitimate needs assessment) and continued funding of State sponsored Risk Pools so that people who are declined for insurance have an affordable option to continue coverage if declined on the individual major medical market. Following these few simple steps will go a long way towards not only maintaining our current health care system, but also towards keeping the bulk of our nations risk where it belongs, namely with the private health insurance sector. In light of the recent multi Trillion Dollar "Bail Outs" and many other failing corporations coming to the table with their hats in their hands (and their private jets on the tarmac) the last thing our government should do is start cutting more blind "bail out" checks in an effort to "reform" the U.S. health care system.


C. Steven Tucker,
Health Insurance Broker
Subject Matter Expert
for The Wall Street Journal
& Fortune Small Business Magazine

First the following on recorded incidence and mortality of prostate cancer, talen from Wiley Interscience Journal. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Part I: international comparisons

The international patterns and trends in prostate cancer incidence, survival, prevalence and mortality were examined. Age-standardized incidence and death rates among men in a variety of countries worldwide were obtained from various sources, survival rates from European sources and elsewhere, and prevalence estimates from the EUROPREVAL study. Results from many published studies were summarized. The incidence of prostate cancer varies widely around the world, with by far the highest rates in the USA and Canada. There has been a gradual increase in the incidence of prostate cancer since the 1960s in many countries and in most continents; there were large increases in the late 1980s and early 1990s in the USA, but increases have also occurred in countries with comparatively low incidence, e.g. India. Survival from prostate cancer improved during the 1970s and 1980s; further increases in the 1990s may be largely a result of earlier diagnosis. There were wide differences in survival across Europe, with rates in the UK well below the average, but all European rates were far below those in the USA. There was wide variation in the prevalence of prostate cancer in Europe; in some countries with high incidence and high life-expectancy, prostate cancers formed ≈ 15% of all prevalent cancers in men. Mortality from prostate cancer has also increased in many countries, but to a lesser extent than incidence; this is consistent with the observed trends in survival. Mortality decreased slightly in the mid to late 1990s in several countries, including the USA, Canada, England, France and Austria. Part of the apparent increases in the incidence of prostate cancer has been associated with diagnostic artefacts (particularly detecting preclinical tumours through the increased use of transurethral resection) which may also have had an effect on death certification through the incorrect attribution of prostate cancer as the underlying cause of death. However, the greatest effect on the registration of new cases of prostate cancer has been the increased availability of prostate specific antigen testing during the early- to mid-1990s. Possibly, in addition to the effect of attribution bias, the earlier diagnosis of prostate cancers has contributed to the recent slight decreases in mortality. However, this is unlikely to account for much of the reduction, given the slow development of the disease from onset to death. Changes in disease management are probably more important. There are many strong arguments against introducing population-based screening for prostate cancer.

If PSA tests and biopsies give false-positive results and unwarranted medical intervention occurs then the results will appear to suggest a higher rate of success as judged by mortality statistics. The same is true to lesser extent in the case of breast cancer. A personal example was my own experienced. My doctor referred me to a surgeon who got an ambiguous result from a biopsy and recommended a mastectomy. I got a second opinion and a further biopsy and have been cancer free for over five years without treatment.

I would also suggest looking at life expectancy in Canada and Germany.Us life expectancy is lower. Table 3. Internationala rankings of life expectancy at birth for females, with Australian life expectancy presented separately for Australian-born and all migrant groups and Global comparative assessments of life expectancy: the impact of migration with reference to Australia


as a broker but you cite many fallacies and distorted data in your for-profit sales pitch. I will deal with many of the problems with this advertisement shortly. :)